Addressing Tobacco Dependence in Psychiatric Practice: Promises and Pitfalls

Abstract

The 2 In Review papers in this issue of The Canadian Journal of Psychiatry focus on tobacco use in mental health and addictive (MHA) populations, which is timely, given the high rates of tobacco use (primarily through cigarette smoking) in MHA settings and the difficulties with smoking cessation that are well documented for MHA patients.1-3 The sobering fact is that in 2009 the primary cause of death in MHA populations is tobacco-related medical illness, such as cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer, and their lives are substantially shorter than the general public in great part owing to tobacco use.4-7 The first article, by Dr Dominique Morisano, Dr Ingrid Bacher, Dr Janet Audrain-McGovern, and Dr Tony George,8 reviews biobehavioural, psychological, and social and (or) environmental determinants of tobacco comorbidity in MHA populations. Converging lines of evidence in the past 20 years indicate that having an MHA diagnosis appears to be a vulnerability factor for the initiation and maintenance of tobacco use and tobacco dependence (TD). Moreover, there is some limited evidence in some mental health disorders (for example, schizophrenia and major depressive disorder [MDD]) that nicotine, the major component of tobacco that leads to drug reinforcement, may actually produce beneficial effects, such as remediation of cognitive deficits in people with schizophrenia911 and improvement of depressive symptoms in MDD. 1214 There are also other explanations for the high rates of TD in these populations, including vulnerability to addiction and enhanced nicotine withdrawal. Clearly more research is needed on this topic. Accordingly, increased knowledge about the role of nicotinic receptors and pathways in MHA disorders has the potential to be translated into novel and more effective treatments, both for the MHA disorders and for comorbid tobacco addiction in these patients, who bear a disproportionate burden of the economic, social, and health care costs associated with tobacco addiction.15 The second article, by Dr Brian Hitsman, Ms Taryn D Moss, Dr Ivan D Montoya, and Dr George,16 describes an evidencebased approach to, and available clinical research data supporting the use of, pharmacological and behavioural interventions for TD treatment in MHA populations. Clearly such treatment is best done in an integrated setting where both treatment for the MHA disorder and the comorbid tobacco addiction are done by the same clinicians in the same facility.1718 In addition, these populations appear to benefit from integrated treatment that includes psychosocial and pharmacological treatments. However, most studies in treatment-seeking MHA smokers have been of a small sample size, and performed at a single site, typically in an academic tertiary health care setting. This has led to limited progress in this field insofar as developing treatments for widespread dissemination and implementation in community settings, where most MHA smokers are managed. A growing number of studies have confirmed that while cessation rates are low, tobacco reduction and cessation in MHA smokers is possible, and in fact some of the more recent studies in smokers with schizophrenia,19'20 which have used optimized treatment strategies, including nicotine replacement therapies, sustained-release bupropion, and cognitive-behavioural and motivational therapies, have produced short- and long-term (6 month) quit rates that approach those in noncomorbid smokers.21 Further, while TD is considered a chronic illness, studies that have examined extended treatments in MHA populations are rare. However, one recent study17 in smokers with a history of MDD achieved very high long-term cessation rates (about 50%) with extended treatment of up to a 1-year duration. Clearly we need to consider maintenance treatments for MHA and other smokers who initially respond to treatment, and provide ongoing treatment support for those . …